1. The Impact of Smoking Cessation Interventions by Multiple Health Professionals Lawrence An, MD 1 ; Steven Foldes, PhD 2 ; Nina Alesci, PhD 1 ; Patricia Bland, MA 2 ; Michael Davern, PhD 1 ; Barbara Schillo, PhD 3 ; Jasjit Ahluwalia, MD, MPH 1 ; Marc Manley, MD, MPH 1 1.University of Minnesota 2.Blue Cross and Blue Shield of Minnesota 3.Clearway Minnesota

2. Outline Background Research Question Methods Results Implications

3. Background 5 A’s for brief intervention include: –Ask about tobacco use –Advise to quit –Assess willingness to make a quit attempt –Assist in quit attempt –Arrange follow-up

4. Background Smoking cessation can be effective when provided by physicians or non-physicians There is a trend toward greater efficacy when intervention is provided by more than one type of health professional Literature shows suboptimal performance on these measures Health professionals cite barriers such as time limitations, lack of compensation, and unfamiliarity with treatments

5. Research Question How do interventions by multiple health providers impact smokers’ quitting behavior?

6. Research Question Paper has three goals: 1.Describe smokers’ reports of cessation interventions by multiple types of health providers

7. Research Questions Paper has three goals: 1.Describe smokers’ reports of cessation interventions by multiple types of health providers 2.Determine the proportion of smokers who receive interventions by two or more types of health professional

8. Research Question Paper has three goals: 1.Describe smokers’ reports of cessation interventions by multiple types of health providers 2.Determine the proportion of smokers who receive interventions by two or more types of health professional 3.Determine how multiple interventions may impact readiness to quit, quit attempts and recent quitting

9. Methods Data Source: 2003 Minnesota Adult Tobacco Survey (MATS) –Representative sample of adults in Minnesota and Blue Cross and Blue Shield of Minnesota health plan (total n = 8821) –Survey questions derived from previous tobacco studies, including: CDC Adult Tobacco Survey California Tobacco Survey

10. Methods Study population: respondents who reported smoking at least 100 cigarettes in their lifetime, including: –Current smokers: individuals who reported smoking “every day” or “some days” –Ex-smokers: individuals not smoking at the time of the survey –Recent ex-smokers: individuals who stopped smoking within the past 12 months

11. Methods All survey respondents identified which types of health professionals they had seen in the past 12 months for their own health, including: –Medical doctor –Dentist –Nurse or nurse practitioner –Pharmacist –Other type of health provider

12. Methods Current smokers and recent ex- smokers who had seen a health professional answered the following: –“In the past 12 months, did any doctor, nurse or other health professional ask you if you smoke?” –If yes, the type or types of health professionals

13. Methods Current smokers also answered the following: –“In the past 12 months, did any doctor, nurse or other health professional advise you to stop smoking?” –Whether health professionals offered assistance, including: Medications Setting a quit date Recommending a cessation program Offering to schedule a return visit or phone call to help them quit

14. Methods Current smokers defined their readiness to quit as one of the following: –Pre-contemplation (not intending to quit in the next 6 months)

15. Methods Current smokers defined their readiness to quit as one of the following: –Pre-contemplation (not intending to quit in the next 6 months) –Contemplation (intending to quit in the next 6 months, but not the next 30 days)

16. Methods Current smokers defined their readiness to quit as one of the following: –Pre-contemplation (not intending to quit in the next 6 months) –Contemplation (intending to quit in the next 6 months, but not the next 30 days) –Preparation (intending to quit in the next 30 days and having made a quit attempt in the past 12 months)

17. Methods Logistic regression analysis using Stata 9.0 complex survey mode Independent variable: dummy variable representing the level of intervention by health providers 1.None 2.One type of health professional 3.Two or more types of health professionals

18. Methods Four separate logistic regression models All models included: –Demographics (age, gender, ethnicity, education level) –Health status –Number of provider types seen in the past year Models 2 – 4 also included: –Number of cigarettes smoked each day –Time to first morning cigarette

19. Methods Model 1: What is the association between the level of professional intervention and the odds that a patient quit smoking in the past year? –Sample: current smokers and recent ex- smokers –Independent variable: number of types of professionals who Asked about smoking –Dependent variable: smoker quit in past year (Yes or No)

20. Methods Model 2: What is the association between the level of professional intervention and the odds that a patient made a quit attempt in the past year? –Sample: current smokers only –Independent variables: number of types of professionals who Asked about smoking, Advised to quit, and Assisted the quit attempt –Dependent variable: smoker made a quit attempt in past year (Yes or No)

21. Methods Model 3: What is the association between the level of professional intervention and the odds that a patient was contemplating making a quit attempt at the time of the survey? –Sample: current smokers only –Independent variables: number of types of professionals who Asked about smoking, Advised to quit, and Assisted the quit attempt –Dependent variable: smoker reported quit status as contemplation (Yes or No)

22. Methods Model 4: What is the association between the level of professional intervention and the odds that a patient was in preparation for a quit attempt at the time of the survey? –Sample: current smokers only –Independent variables: number of types of professionals who Asked about smoking, Advised to quit, and Assisted the quit attempt –Dependent variable: smoker reported quit status as preparation (Yes or No)

23. Results Response rate: 56.5% (n = 8821) Overall smoking prevalence: 18.0% Of current smokers and recent ex-smokers (n = 1723): –59.8% made a quit attempt in the past year –8.7% no longer smoke

24. Results SOURCE: 2003 Minnesota Adult Tobacco Survey

25. Results SOURCE: 2003 Minnesota Adult Tobacco Survey

26. Results SOURCE: 2003 Minnesota Adult Tobacco Survey

27. Results SOURCE: 2003 Minnesota Adult Tobacco Survey Percent of smokers reporting health visits, by type of health professional: 2002-2003

28. Results Of current smokers and recent ex-smokers (n = 1723) –65.5% visited 2 or more types of professional –24.4% visited 4 or more types of professional Of those reporting at least one visit (n = 1523) –34.3% reported that more than one type of professional Asked about smoking

29. Results SOURCE: 2003 Minnesota Adult Tobacco Survey Percent of current smokers reporting smoking cessation intervention, by type of health professional: 2002-2003

30. Results SOURCE: 2003 Minnesota Adult Tobacco Survey

31. Results Model 1: Among current smokers and recent ex-smokers, being Asked about smoking by more than one type of professional was significantly associated with quitting in the past year. –Sample: current smokers and recent ex- smokers –Independent variable: number of types of professionals who Asked about smoking –Dependent variable: smoker quit in past year (Yes or No)

32. Results

33. Models 2 – 4: Among current smokers only, being Asked about smoking by more than one type of professional was not significantly associated with any of the measured outcomes: –A quit attempt in the past 12 months –Intent to quit in the next 6 months –A plan to quit in the next 30 days

34. Results Model 2: Among current smokers only, being Advised to quit by more than one type of professional was significantly associated with an attempt to quit in the past 12 months –Sample: current smokers only –Independent variables: number of types of professionals who Asked about smoking, Advised to quit, and Assisted the quit attempt –Dependent variable: smoker made a quit attempt in past year (Yes or No)

35. Results

36. Model 3: Among current smokers only, being Advised to quit by more than one type of professional was significantly associated with an intent to quit in the next 6 months –Sample: current smokers only –Independent variables: number of types of professionals who Asked about smoking, Advised to quit, and Assisted the quit attempt –Dependent variable: smoker reported quit status as contemplation (Yes or No)

37. Results

38. Model 4: Among current smokers only, there was no significant association between the level of professional intervention and the odds that a patient was in preparation for a quit attempt at the time of the survey –Sample: current smokers only –Independent variables: number of types of professionals who Asked about smoking, Advised to quit, and Assisted the quit attempt –Dependent variable: smoker reported quit status as preparation (Yes or No)

39. Results Models 2 – 4: Among current smokers only, being offered Assistance in quitting by more than one type of professional was not significantly associated with any of the measured outcomes: –A quit attempt in the past 12 months –Intent to quit in the next 6 months –A plan to quit in the next 30 days

40. Results Summary 65.5% of current smokers and recent ex- smokers reported visiting more than one type of provider in the past year 34.3% of individuals with visits in the past year reported that more than one type of professional Asked about smoking Medical doctors and nurses/nurse practitioners were the professionals most cited for asking about tobacco use

41. Results Summary Being Asked about smoking by more than one type of health professional was associated with increased odds of successfully quitting in the past year Being Advised to quit smoking by more than one type of professional was associated with increased odds of a quit attempt or intent to quit

42. Limitations Due to the cross-sectional nature of this study, further research is needed to examine issues of causation and confounding factors –Timing of brief interventions and quit attempts –Frequency of visits and interventions –Overall health state and disease progression

43. Implications Study supports previous work demonstrating the effectiveness of brief interventions Increased odds of quitting observed in this study are comparable to other types of tobacco control –Home or workplace bans –Exposure to anti-tobacco media

44. Implications Reducing tobacco-related disease is a challenge for all health providers Activation of professional types across the health care system has the greatest potential to increase quitting and readiness to quit among smokers